Clinical Question

Are opioids effective in alleviating pain in adults with acute nonspecific low back or neck pain?

Bottom Line

In the rigorously conducted study, from week to week over a six-week period, adults with acute low back or neck pain treated with opioids had similar pain relief as those treated with placebo. (Level of Evidence = 1b)

Synopsis

The researchers recruited adults with less than 12 weeks of new-onset low back or neck pain who sought care from their primary care physician or in an emergency department. The patients could have radicular symptoms, but no alarm symptoms, and they had to have pain of at least moderate severity. The authors randomized the patients to receive an opioid (oxycodone, 5 mg twice daily and naloxone, 2.5 mg, titratable to 10 mg of oxycodone; n = 174) or placebo (n = 172). The patients were treated until their pain score was 0 or 1 out of 10 for three consecutive days or for a maximum of six weeks. Although the researchers assessed the participants at two, four, six, 12, 26, and 52 weeks after enrollment, the primary outcome was pain on a 10-point visual analog scale at six weeks. At baseline, both groups had similar pain ratings (5.7 and 5.6, respectively). After six weeks, more participants dropped out of the opioid group (19%) than the placebo group (15%). The remaining participants in both groups improved by a similar degree (2.8 and 2.2, respectively). At no point during the 52-week follow-up did patients treated with opioids experience more pain relief than patients treated with placebo. At a few points in time, patients treated with placebo had greater pain relief. The masking of participants worked— roughly one-half in each group could not guess their treatment assignment. Approximately one-third of participants in each group experienced adverse events, but serious adverse events were infrequent (4% and 2%, respectively). In pain studies, a change of 2 points on a 10-point scale is generally considered to be clinically meaningful. The study reported only average changes and did not report the proportion of participants in each group who achieved this threshold, thereby leaving the question of whether some patients respond better to opioids than others unanswered.